A Pediatricians' Raw Experience in Private Independent Medical Practice on the front lines.

Tuesday, August 1, 2017

Healthcare Plan: Reboot and Rebuild

I told you so.I also told the POTUS in my open letter,
but he did not read it.Who could honestly
believe the nation would support dumping coverage for 22 million people?According to an op-ed
in the New York Times: “They [Republicans and President Trump] had only one big
weakness, in fact: They weren’t dealing in reality.”When faced with reality, it is interesting
what a few good Senators with a conscience will refuse to do.

Success is never attained by taking shortcuts. We do not need reform of health care; we need to renovate the entire system.Special interests do not belong in the picture.They are superfluous to achieving innovative
solutions that place profits on the back burner.Healthcare reform is like learning to
discipline a tantrum-throwing 3-year-old; it will not conform to rhyme or reason.Congress
is making this too difficult.They need
to roll up their sleeves, go back to the drawing board, and start again.My suggestions:

Step 1:Every
member of Congress should participate in a mock hospital admission as a
patient, starting with presentation to the ER, being poked and prodded, having
surgery if necessary, and staying overnight to recuperate.After your experience, you should be provided
a “bill” on your way out the door and pay the balance by cash or check.

Step 2:Go
see your own primary care physician for two reasons.The first is to have an annual exam and to connect
with your constituents in the waiting room, solicit their comments, thoughts,
or suggestions, and converse with office staff to understand their
perspective.The second reason is to
elicit feedback directly from your primary care physician.Listen for groundbreaking solutions to the
perplexing boondoggle of caring for greater numbers at a lower cost.

Extra credit:Follow a primary care physician in a Health Professional Shortage Area (HPSA)
for three days.Listen, engage, clarify,
empathize, and most importantly absorb how monumental this undertaking of
reforming health care will be.

Step 3: Return to Washington D.C. inspired and reboot,
resolving to do it right this time.

The
nation has been having entirely the wrong conversation; that dialogue must change.The biggest obstacle faced by lawmakers is
maintaining access while reducing cost.Providing
coverage without coupling it to budgetary constraints is sheer lunacy.However, reducing government involvement in
coverage without ensuring the needy can afford health care will never garner
widespread support.Affordability has
become an impossible dream and is currently our largest stumbling block.

The
U.S. spent $10,345
per person annually in 2016.The average
OECD country spends $3997 per person annually in comparison.During the 1980’s Spain created a network of community
health clinics within a 15 minute radius of every citizen, a system which was
funded by the taxpayers.In 1975, the
average life expectancy from birth was equivalent in both nations, at 69 years
of age.Today, life expectancy in Spain
is 83 years compared to 78.8 in the United States.We are spending twice as much as Spain and
our life expectancy is significantly lower.

An appropriate policy goal would be to focus on
developing a durable healthcare foundation, poured only after great deliberation.Scaffolding already exists, in community
clinics and Public Health departments; these facilities are cost-effective, yet
grossly underfunded, underutilized, and unappreciated.Every single man, woman, and child needs
primary care services, a fact which in incompatible to the insurance model.We must sever the connection between
insurance and primary care.Providing
basic care universally is something we must accept as reality. As I have
written before, investing in primary
care as a solution is a no-brainer; increasing by one PCP/10,000 persons decreases mortality by
5.3%.

Basic
care will bring us all out from the shadows and into the light.Provide immunizations, screenings, and annual
exams to everyone in this country.Those
working in the community clinics will be employed by the government and
salaried.These clinics could have
evening or weekend walk-in hours and handle urgent matters.The electronic medical records system should
be universal and patient-centric.People
will no longer live in fear of our government eliminating access for chronic
conditions or emergencies. Struggling
families will not be one catastrophic illness away from losing their hopes and
dreams.

As
we continue filling in the grid, specialty care should be added at the public
health facilities or community clinics.A
specialist would cover a greater number of patients when overseeing or
consulting on difficult cases with the primary care physicians.These specialists would be employed by the
government and salaried as well.If an
individual becomes severely ill or injured and requires very specialized treatment,
hospitalization, or surgical management, either they have Medicaid, Medicare,
or their catastrophic insurance plan kicks in to cover these needs.

No
discussion would be complete without including third party payers, who distance
patients and physicians from being cognizant of cost.For what we do in our offices, services could
be far cheaper.For example, a
self-employed middle-aged patient with a $25,000 deductible sustained a 4cm
laceration to the head and went to buy glue to repair it himself.On this particular holiday weekend, the
stores were already closed.He inquired
as to the cash price for repair after texting a picture.

I
had no answer, but primary care physicians love repairing lacerations and I am
no exception to the rule.He came to my office;
I cleaned the wound and sutured it.He
handed me his credit card, similar to the cashier at a grocery or hardware
store.Supplies cost roughly $50; the
laceration repair took 15 minutes.I
figured $150 seemed reasonable.He paid $200
and was thrilled.

While
the lack of transparency hindered my research, I compared the cost to repair a
4 cm laceration in the emergency room.The
estimated charges were: $1000 emergency
room facility charge, physician cost $500, and the procedure bill was $200.My hardworking patient would have coughed up
$1700 at a minimum (some estimate as high as $1000 per stitch) and waited well
over 15 minutes for the privilege.

Allow
the free market forces to remain a part of the infrastructure.A great deal of the population fears a
universal basic system because they are afraid of losing choice.Direct Primary Care practices would flourish in
a system with a basic care safety net for those in need.Those who can afford choice would have
options to patronize the private market, which absolutely should not be
eliminated.

Reviewing
the events this week reminds me Rome was not built in a day. Repairing the
tangled web of health care will take unconventional thinking and the tincture
of time. Costs have spiraled out of control past the point of affordability.The nation will only support reform once
Congress overhauls our broken system prior to embarking on repealing anything. Finally, everyone is profiting except the two
most critical components: the physicians and their patients.Renovate, reboot, and rebuild from the ground
up and when you do, start by putting patients ahead of profits.